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Examination of Integration of Native 
and Non-Native Health Care 







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November, 2005 




A project funded by the Federal Office of Rural Health Policy, via Order No. 
03H1 162620 ID, in collaboration with Mountain States Group, Inc. 



TABLE OF CONTENTS 

I. PURPOSE OF STUDY 4 

II. EXECUTIVE SUMMARY 5 

III. BACKGROUND 10 

A. Project History 10 

B. Brief History of Health Services to Alaskan Natives/Native Americans . . .10 

C. Section 330 Community Health Clinic Program Use by Tribal Entities . . .15 

IV. METHODOLOGY 18 

V. RESULTS 20 

Menominee Tribal Clinic 20 

Feather River Tribal Health 26 

Benewah Medical & Wellness Center 32 

Montezuma Creek Community Health Center 38 

Norton Sound Health Corporation 44 

VI. SUMMARY 49 

VII. APPENDICES 54 

1. Administration questions 55 

2. Community questions 57 

3. Ranking matrix for site selection process 59 

4. Participation confirmation forms 60 



I. PURPOSE 

An important constituency group among rural residents is American Indian and Alaskan Native 
(AI/AN) communities. Throughout the US and particularly in Alaska, distinct health care 
systems often provide overlapping or duplicative services. Examples include, for instance, 
Tribal health consortia, public health safety net clinics and Veterans Administration clinics. In 
many rural and frontier communities, limited resources and sparse populations necessitate the 
collaboration of Native and non-Native health systems, e.g., collaboration between Federally 
Qualified Health Centers (FQHCs) and Indian Health Services (IHS)-funded health care 
facilities. While such collaboration is increasing throughout the country, no quantitative or 
qualitative data is available that provides an understanding of the circumstances under which 
such collaboration is successful or unsuccessful. If such information were available Native and 
non-Native health care systems that are currently collaborating or wish to collaborate would be 
better able to plan for or maintain successful collaboration. 

To that end, in FY 2003 the Health Resources and Services Administration's (HRSA) Federal 
Office of Rural Health Policy (ORHP) funded a study designed to identify, analyze and describe 
health systems that routinely integrate the care of Tribal beneficiaries and non-Tribal community 
members. For purposes of this study, integration was defined as "the routine provision of 
services to all population groups (Native American and non-Native American) from a sole 
source or site". 

Nationally five sites have been identified to participate in a qualitative study of the effects of 
integrating Native and non-Native health care. These sites have served as case studies for this 
project and the information gleaned from these sites has provided the basis for this report. 

The purpose was to identify instances where such integration has occurred and to understand 
why and where integration has been successful, and why and where it has been less successful. 
Ultimately, the knowledge gained will result in an understanding of Native/non-Native 
integration and this knowledge will be nationally applicable as one method for expansion of 
access to care and increased availability of a greater number of services to rural communities. 



II. EXECUTIVE SUMMARY 

HRSA's Federal Office of Rural Health Policy (ORHP) funded a study designed to identify, 
analyze and describe health systems that routinely integrate the care of Tribal beneficiaries with 
non-Tribal community members. For purposes of this study, integration was defined as "the 
routine provision of services to all population groups (Native American and non-Native 
American) from a sole source or site". A small Work Group was identified that included 
provider representatives from both Native American and non-Native American healthcare 
systems, representatives from the Indian Health Services, HRSA's Bureau of Primary Health 
Care (BPHC), State Offices of Rural Health (SORH), and academic researchers with an 
understanding of Native American issues and/or rural health issues. The work group provided 
background information for the study and reviewed and approved the study process, case study 
selection criteria, and key informant questions to be used at the site visits. 

A qualitative study was conducted of the effects of integrating Native and non-Native health 
care. The purpose was to identify instances where such integration has occurred and to 
understand why and where integration has been successful, and why and where it has been less 
successful. Ultimately, the knowledge gained will result in an understanding of Native/non- 
Native integration and this knowledge will be nationally applicable as one method for expansion 
of access to care and increased availability of a greater number of services both to Tribes and 
rural communities. 

Nationally five Tribal sites were identified to participate based on the location, the type of 
facility (community health center, hospital, non-profit), the longevity of the integration and the 
percentage of non-Native patients. These sites were selected from a list recommended by the 
State Offices of Rural Health, Indian Health Service, consultants and others. The list was 
narrowed down according to geographic representation, inpatient vs. outpatient, how well the 
site met the integration definition, Tribally operated, etc. These sites have served as case studies 
for this project and the information gleaned from these sites has provided the basis for this 
report. The five sites include the Menominee Tribal Clinic in Keshena, Wisconsin, the Feather 
River Tribal Health Center in Oroville, California, the Benewah Medical & Wellness Center in 
Plummer, Idaho, the Montezuma Creek Community Health Center in Montezuma Creek, Utah, 
and the Norton Sound Health Corporation in Nome, Alaska. The map page 11 depicts the 
location of these five study sites. 

A total of 98 interviews were conducted at these five sites using a key informant interview 
questionnaire developed for two audiences - facility administrative/clinical personnel and 
community members (refer to Appendices 1 and 2). The interviewees included employees of the 
facilities (administration/fiscal, clinical providers), Tribal board members, community board 
members, and patients (both Native and non-Native). 

The following summarizes major points about initial barriers to integration, issues today that are 
different than initial stages, advantages of integration and one greatest benefit, disadvantages of 
integration, improvements or changes to access to care, key factors that other tribes should 



consider if contemplating integration, and whether they would pursue integration if given the 
opportunity to do it again. 

Barriers: 

• Increased growth/demand for services 

• Declining public perception regarding quality of services 

• Limited services available to non-Natives 

• Fears: loss of Tribal identity, loss of access, loss of focus on Natives, loss of revenues 

• Lack of IHS support and technical assistance in forming integrated models 

• Lack of leadership experience (administration/board) 

• Coordination of dollars due to regulations 

Current Issues: 

• Perceived discrimination by non-Natives 

• Inability to hire Natives 

• Difficulties in balancing the needs of both populations 

• Much more complex in terms of management/administration 

• More liability risks to tribes 

Advantages: 

• Enhanced sharing/respect for diversity 

• Increased continuity of care 

• Decreased prejudice 

• Increased access for all 

• Increased economic independence 

• Diversified funding sources leads to more comprehensive care 

• Increase public relations and community support 

• Increased quality of care 

• Increased resources to support service expansions, staff, and new facilities 

• Increased choice 

• Enhanced provider recruitment and retention 

One Greatest Benefit: 

• Diverse funding stream leads to increased resources 

• Increased resources leads to improved quality and access to care 

• Increased quality and access leads to improved community/public relations 

• Improved public relations leads to increase utilization 

Disadvantages: 

• Two tiered system discriminates against non-Natives 

• Increased liability risk to tribes to treat non-Natives (malpractice/HIPAA) 

• Decreased access to Natives (appointment time access) 

• Multiple reporting requirements 

• Management complexities 



• Cumbersome regulations 

• Billing/collection knowledge requirements and issues 

• Structure could lose focus on Native needs 

• Stricter policies/more businesslike operations 

Access Improvements/Changes: 

• Improved variety of services 

• Local access to specialty services 

• Increased choice of providers 

• Greater capacity 

• Increases hours of service 

• Less wait time 

• Longer waits but more choice 

• Increased outreach efforts 

• Better and more providers 

• More training opportunities for staff 

• Increased respect 

Key Factors if Contemplating Integrated Services: 

• Strong continuous leadership 

• Clear vision and realistic expectations 

• Anticipate tensions; educate all parties; develop plan 

• Involve all parties in planning meetings; inform community and Tribal members 

• Integrate staff and board 

• Focus on infrastructure by having policies in place, businesslike operations, training for 
staff 

• Study/explore funding sources 

• Hire a grant writer 

• Build financial reserves 

• Reduce politics and increase teamwork 

• Hire good staff 

• Provide high quality services 

• Focus should be on the patient needs 

• Do a feasibility study and comprehensive planning 

• Understand third party payer reimbursement (including Medicaid and Medicare) 

Would Repeat: (all would pursue integration again) 

• Integration is better for everyone 

• Diversity makes us stronger, decreases tension between Natives/non-Natives 

• Benefits far outweigh the liabilities 

• Best mechanism for maintaining/improving independence/self-reliance 

• Many improvements in healthcare made possible due to diversified funding sources 



Summary: 

Many of the interviewees stated that offering integrated services was the right thing to do 
because sharing is part of their value structure. At sites that were remote, such as Norton Sound 
Health Corporation, Benewah or Montezuma Creek, the interviewees noted that if the Tribe 
didn't open their services to non-Natives, there would be no local access to health care for non- 
Natives. In Nome, the nearest healthcare would be 500 miles away in Anchorage if the tribe 
didn't share services. 

All of the health care administrators and board members indicated that the financial benefit by 
billing third party payers and accessing grants through integrated services allowed the clinics to 
hire additional providers, access specialists, offer preventive care services, and upgrade facilities. 
The quality of care increases as a result of IHS funding alone would not cover basic primary care 
or contract health services. A few of the tribes indicated that the revenue from third party payers 
covered contract health services that were over the IHS allotment. 

All of the sites offered a sliding fee scale for uninsured patients; however, it was promoted and 
more widely utilized at the sites with Community Health Centers (Benewah, Nome and 
Montezuma Creek). The other sites were concerned about keeping up with demand for services 
and wanted to keep appointments available for Native patients that they indicated were the 
priority. 

Integration has significantly benefited these Tribal entities in terms of improvements in resources 
(diversified revenue streams/increased revenues/staffing/facilities) which has led to improved 
quality of care, more comprehensive care, and enhanced public perceptions. The path to 
integration was also fraught with tension and challenges of change that were overcome with 1) 
strong, visionary leadership, 2) the use of an inclusive process that involved representatives from 
both Natives and non-Natives, 3) a recognition that education and information must be shared 
openly with all involved, 4) a thorough planning process to identify community needs, explore 
funding options and rules/regulations, 5) infrastructure improvements including adequate skilled 
staff (e.g. management, clinical, grant writer, etc.), staff training (billing/collection processes), 
and adequate computer resources and IT support, and 6) clear, reasonable expectations of 
outcomes. 

All participants at the Tribal sites enthusiastically embraced the decision to integrate their 
services. When asked if they would repeat their integration efforts if given the opportunity, all of 
them expressed without hesitation, they would definitely pursue that option. Tribal health 
systems around the country who are operating under the provisions of Self-Determination 
Contracting under P.L. 93-638 or Self-Governance Compacting under Title V, have a unique 
opportunity to enhance their health care by learning from this study that there are numerous 
benefits and challenges that are worth exploring. 

Issues/Recommendations: 



The statement earlier this year by IHS that the Federal Tort Claims Act would not cover 
malpractice claims for non-Natives was mentioned by 3 of the 5 sites as a potential barrier. The 



sites purchased additional malpractice insurance to cover any potential gaps, although the 
administrators weren't sure if it was actually needed. 

The reporting regulations for IHS and BPHC are duplicative, yet utilize different standards. 
Many of the sites indicated that the RPMS, the IHS software for tracking patients and services, 
was cumbersome and didn't work well with an integrated clinic. 

Pharmacy regulations and costs were mentioned frequently by providers, patients and 
administrators. Pharmacy formularies are different for Community Health Centers (CHC) with 
the 340(b) program, IHS, third party payers, and cash patients, causing some of the pharmacies 
to have three different formularies. Two of the clinics had limited pharmacy services to clinic 
patients only. Community members at the non-community health center sites often noted that 
the cost of pharmaceuticals was prohibitive for non-Native patients. 

CHC funding specifically for Native sites was cited by a few administrators and board members 
as an incentive for integrated Tribal clinics to apply for 330 grants. They noted that there the 
grants are highly competitive and many were not aware of technical assistance resources for 
grant applications through state Primary Care Associations. We also found that they sites with 
critical access hospitals were not aware of the Rural Hospital Flexibility Grant Program 
Technical Assistance and Services Center. The clinic leaders noted that technical assistance 
would be helpful in forming a non-profit, operating under the provisions of Self-Determination, 
P.L. 93-638, Title 1, or applying for CHC funding. 

Minimizing the loss of Tribal identity was a core issue to the successful integration at these five 
study sites. Assurances and maintenance of cultural values were pivotal to their ability to 
establish an integrated health care system. Workforce issues were also addressed by many of the 
interviewees. Recruitment of needed personnel and gearing up to handle the increased volume 
of patients created through integration were identified as issues that needed to be addressed. 
None of these were identified as insurmountable barriers, but each site had to address them 
before, during, or shortly after integration. 

Based on the number of issues identified, the following are some initial recommendations for 
future policy development. 



> Develop a Technical Assistance Center for Tribes contemplating serving non-Natives. This 
center could provide support to Tribes in the areas of governance models, reimbursement 
issues, billing and collections, grant development, risk management, pharmacy formularies, 
and networking. 

> Pilot the establishment of a separate joint funding announcement open to all tribes (638 or 
self-governance). HRSA/BPHC in conjunction with IHS could pilot test integration 
activities that would consolidate reporting requirements, pharmacy regulations, liability 
issues, etc. 

> Provide technical assistance workshops in each IHS region. The first day would increase 
awareness of options available to tribes interested in providing integrated services and 
highlight Tribal entities that have successfully integrated services. The second day could 



focus on specific issues related to obtaining Community Health Center funding, e.g. 
infrastructure needs, regulatory differences governing Tribal versus CHC entities, software 
incompatibilities between IHS and BPC, conflicting policies/procedures, and grant 
development support. 



III. BACKGROUND 

A. Project History . In the Fall 2003, HRSA's ORHP initiated a study of Tribal sites that 
provided services to non-Natives. In January 2004, ORHP convened a meeting in Denver, 
Colorado to bring project personnel from this study and another sponsored project study 
managed by the SouthEast Alaska Regional Health Consortium (SEARHC). The SEARHC 
project objective was to study the qualitative and quantitative impacts of integrated health 
delivery model at 2 locations in SE Alaska. The primary purpose of this joint meeting was to 
identify topics and questions common to both ORHP-sponsored studies on Tribal/non-Tribal 
healthcare integration, and to the extent possible, agree upon wording and measurements for 
those topical questions to be shared by both teams. Participants included: Bonnie Boedeker, 
Sally Buck, Kathy Hayes, Gary Leva, Bernie Osberg, Paul Kirisitz, Marcia Brand, Mark 
Gorman, Terry Hill, Jeannie Monk, and Linda Powell. The results of this meeting as it pertains 
to this study included an identification of the Work Group, clarification of terminology, 
discussion and development of site selection criteria, discussion of study questions and scope of 
project. Project differences were identified and discussed. The SEARHC study is focused on 
internal operational histories at two Alaskan sites. Project staff will have direct access to all data 
required. The MSG study is focused on five sites nationally. Project staff will not have direct 
access to all desirable data. The analogy is the MSG study is a view from 5,000 feet versus the 
SEARHC study which is a view from 5 feet. The consensus of this group was that both projects 
would try to incorporate some questions that were worded identically in order to explore and 
possibly compare results. 

After the meeting in Denver, the project's Work Group held several conference calls to finalize 
the study design, finalize the interview questions, finalize site selection criteria, and select the 
case study sites. Five sites were selected and project staff began contacting representatives to 
arrange for site visits. The site visits were scheduled and held, the interviews were completed, 
the results were documented, and this document was developed by project team members. The 
Work Group reviewed and edited the final draft prior to submission to ORHP. For a detailed 
description of the study methodology, please refer to the section entitled Methodology. The map 
on the following page depicts the location of the study sites. 

B. History of Health Services to American Indians/Alaskan Natives (AI/AN) . In order to 
understand the historical basis for the development of non-integrated services and why a study of 
sites that figured out how to provide integrated services is necessary, a brief historical overview 
is needed. Much of this section comes from an issue brief developed by the Henry J. Kaiser 



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Family Foundation l , an article on the history and politics of US health care policy for AI/AN 
people 2 , and is supplemented by materials from the IHS 3 . 

Health care for AI/AN people typically comes from a system that is separate from mainstream 
America. The Indian Health Service (IHS), part of the US Department of Health and Human 
Services (DHHS), is currently the Federal agency with primary responsibility for fulfilling the 
United States' trust obligation to provide health care for AI/AN people. The IHS and tribes have 
developed a system of hospitals, clinics, field stations, and other programs in the attempt to meet 
the health care needs of AI/AN people. 

The legal and historical background in which the Indian health care system exists is the result of 
an ever-changing political landscape. There have been different time periods during which 
distinct policies dominated, but legal doctrine "threads" remain from each period long after the 
period itself has passed. From the beginning, Tribal sovereignty, government-to-government 
relations between tribes and the United States, and Tribal autonomy have existed as common 
themes underlying Federal-Indian relations. In addition, a unique Federal trust responsibility has 
grown as a result of the relations between the Federal government and tribes. 

Along with these common themes, there have been shifts between US policy preferences for 
assimilation or for self-determination of Indian people. New laws have developed as the 
political landscape has changed over the decades while older laws remain intact or are 
reinterpreted in light of prevailing political perspectives. Figure 1 is a timeline of major 
legislative and historical events in health care for AI/AN people. 1 

The shifts in the political landscape moved from a policy of conquest, to treaty-making, to 
assimilation, to reorganization, to termination, and finally to self-determination. Federal laws 
and policies in the mid-1970s greatly altered the profile of the Indian health care delivery system. 
The Indian Self-Determination and Education Assistance Act (ISDEA) of 1975 grants tribes the 
option of contracting for the health care services that they would otherwise receive directly from 
the IHS. The Indian Health Care Improvement Act (IHCIA), passed in 1976, increased 
participation of Tribal members in their health care system by funding, among other things, 
scholarship programs for Indian students and by involving tribes further in the planning and 
implementation of Indian health care services. These two pieces of legislation provided 
significant financial resources for the expansion of health care services. Many aging medical 
facilities have been modernized and new hospitals, clinics, and health stations have been 
constructed. 

Since then, tribes have been able to assume some control over the management of their health 
care services by negotiating contracts with IHS Subsequent amendments to the ISDEA have 
strengthened the Federal policy of self-determination for Indian people. In 1994, the ISDEA was 
amended to authorize a Tribal Self-Governance Demonstration Program, which greatly expanded 



1 Shelton, Brett Lee. "Issue Brief: Legal and Historical Roots of Health Care for American Indians and Alaska 
Natives in the United States", The Henry J. Kaiser Family Foundation, February 2004. 

2 Kunitz, Stephen J. "The History and Politics of US Health Care Policy for American Indians and Alaskan 
Natives", American Journal of Public Health; October 1996, Vol. 86, No. 10. 



3 



Indian Health Service - a Culture of Caring, 2003 

12 



Figure 1 



Full Tribal 
sovereignty 



U.S. 
Constitution 



Indian health care 

services 
transferred from 
War Department 



Indian Self-Determination 
and Education Assistance Act 

Indian Health Care 
Improvement Act (IHCIA) 




Indian Reorganization Act 



2000 



Bills introduced in 
Congress to 
reauthorize IHCIA 



13 



this partnership effort by simplifying the self-determination contracting processes and facilitating 
the assumption of IHS programs by Tribal governments. It also authorized the transfer of IHS 
funds directly to Tribal control under a compacting process. The Tribal Self-Governance 
Amendments of 2000 established a permanent self-governance program within the IHS and also 
authorized a study of the feasibility of including other Department of Health and Human 
Services agencies in the self-governance program. 

Whether through contracts, grants, or compacts, nearly all the more than 560 federally 
recognized tribes have exercised their option to assume some level of responsibility for their own 
health care problems. Since 1992, Tribal organizations have negotiated 56 compacts with the 
IHS Today, more than 50 percent of the IHS appropriated budget is allocated to Tribally 
managed programs through compacts and contracts. There has been a shift in the role of the IHS 
from direct care provision to support of Tribally managed health care programs. Tribes now 
operate and staff almost 80 percent of outpatient clinics and other ambulatory care facilities. The 
IHS still provides the majority of inpatient services, operating more than 70 percent of all 
hospitals. However, tribes now manage over 60 percent of the Service Units, providing local 
administrative support to the hospitals, clinical, and community health programs. 

The Indian health care delivery system serves approximately 1.6 million of the Nation's 
estimated 2.6 million American Indians and Alaska Natives. These beneficiaries belong to more 
than 560 Federally recognized tribes and reside primarily on reservations or in rural communities 
in 35 States. Refer to the map on page 17. Medical and dental care is provided at more than 600 
direct health care delivery facilities, including hospitals, health centers, school health centers, 
health stations, and health clinics. Also, some care that is not available at Indian Health Service 
facilities may be obtained through contracted health care providers. The IHS portion of the 
delivery system is organized into 12 regional administrative offices known as Areas, which are 
further divided geographically into more than 150 smaller administrative units called Service 
Units. Each Service Unit may include a federally or Tribally operated hospital plus a 
combination of health centers, school clinics, and/or other smaller health facilities. 

The services available through the IHS are for eligible individuals only. Eligibility factors for 
Contract Health Services include: 

1 . An individual must be of Indian descent and belong to the Indian community which may 
be verified by Tribal descendency or census number. A non-Indian woman pregnant with 
an eligible Indian's child is eligible for CHS during pregnancy through post partum 
(usually 6 weeks). 

2. An individual must reside within his/her Tribal Contract Health Service Delivery Area 
(CHSDA). The Tribal CHSDA encompasses the Reservation, trust land, and the counties 
which border the reservation. The following individuals also meet the residency 
requirements: 

a. Students who are temporarily absent from his/her CHSDA during full-time attendance 
of boarding school, college, vocational, technical, and other academic education. The 
coverage ceases 1 80 days after completing the study. 

b. A person who is temporarily absent from his/her CHSDA due to travel, employment, 
etc., eligibility ceases after 180 days. 



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c. Children placed in foster care outside of the CHSDA by court order. 

d. Other Indian persons who maintain "close social and economic ties" with Tribe. 

3. CHS funds are limited to medical and dental services which are considered medically 
necessary and listed within the established Area IHS medical/dental priorities. 

4. An individual must apply for and use all alternate resources which are available and 
accessible, such as Medicare A and B, State Medicaid, State or other Federal health 
program, private insurance, etc. The IHS is "payor of last resort" of persons defined as 
eligible for CHS notwithstanding any state or local law or regulation to the contrary. The 
IHS facility is also considered a resource, and therefore, the CHS funds may not be 
expended for services that are reasonably accessible and available at IHS facilities. 

5. The Federal regulations require proper notification of the appropriate IHS official before 
CHS assistance is authorized. (Non-emergency and emergency situations are defined). 

To be eligible for CHS, an individual must meet all five eligibility factors listed above and IHS is 
not obligated to pay for medial and dental services under the CHS program unless funds are 
available and authorized. 

C. Section 330 Community Health Clinic Program Use by Tribal Entities . Community Health 
Centers (CHCs) were first funded by the Federal Government as part of the War on Poverty in 
the mid-1960s. By the early 1970s, about 100 neighborhood health centers had been established 
under the Economic Opportunity Act (EOA). The Public Health Service (PHS) began funding 
neighborhood health centers in 1969. With the phase-out of the EOA in the early 1970s, the 
centers supported under this authority were transferred to the Public Health Service. Currently, 
the CHC Federal grant program is authorized under Section 330 of the Health Centers 
Consolidation Act of 1996. In FY 2003, there were 789 community-based public and private 
non-profit CHC grantees that supported over 3,000 clinics. 

Project principals tried various avenues to identify how Tribal entities fared competing for new 
CHC grants. According to a report dated September 2004 entitled "Strengthening HRSA and 
IHS. Efforts to Best Serve the American Indian and Alaska Native People, HRSA-IHS 
Collaboration Progress Report, there were fourteen new Section 330 applications from Alaska in 
FY 2002; three from Alaska and four from the lower 48 states in FY 2003; and two from Alaska 
and two from the lower 48 in FY 2004. There was no data available regarding the number of 
approved applications presented in this report. 

A contact within HRSA's BPHC provided the only data we were able to gather (outside the 
HRSA report cited above). Reportedly, in 2001, there were 236 new CHC applications of which 
106 were approved and funded; no data was available on whether any were Tribal entities. 
According to the Alaska Primary Care Association, four Alaskan Tribal entities were funded in 
2001. In 2002, there were 390 new CHC applications and 171 were approved and funded, none 
were Tribal entities (as evidenced by the check box on the application face page). However, the 
Alaska Primary Care Association reports that ten Alaskan Tribal entities were funded in 2002. 
In 2003, there 468 new CHC applications, four reportedly from Tribal organizations. One 
hundred of those were approved and funded, two of which were from Tribal organizations. 

An attempt was made to determine the number of existing CHC grantees that were Tribal entities 
in order to determine how many more might benefit from integration efforts. The Uniform Data 



15 



System (UDS) data was downloaded from 2003 for all 10 regions. Each region was reviewed to 
determine whether the grantee named was also listed on the IHS comprehensive list of tribes 
published in the Federal Register July 12, 2002 (Volume 67, Number 134) Notices [Page 46327- 
46333]. There were 336 tribes in the contiguous U.S. and 225 Alaska Native Tribes. Excluding 
Alaska, there were only three CHC grantees that were confirmed as Tribal entities (comparison 
of Tribal name to CHC grantee name) and two more that were possibly Tribal entities. It appears 
from this review that a minimum of 300 tribes in the contiguous U.S. might potentially benefit 
from integration. It is not known exactly how many of these tribes have compacts. We do know 
that according to the Office of Tribal Self-Governance web site, there are 61 compacts and 81 
funding agreements. This would be an additional step needed if a Tribal entity was to pursue the 
provision of integrated services. 



16 



IV. METHODOLOGY 

In September 2003, ORHP contracted with Mountain States Group (MSG) to conduct a 
study of Native American/ Alaskan Native health care facilities that provided care to non- 
Native populations. The contract tasks included identifying the sites for case study, 
identifying experts to provide direction and guidance (work group), conducting key 
informant interviews at each site to gather information, and compiling, analyzing, and 
interpreting the data into a formal report. 

An initial literature review was completed to identify other publications, articles, or 
research in the area of Tribal integrated healthcare. Although a variety of documents 
were found describing the existing health disparities of Native American/Alaskan 
Natives, none were found that addressed Tribal integrated healthcare. The project 
principals met on November 18, 2003 to identify all possible questions to include in the 
key informant interview process, to assign responsibilities for contacting IHS and all 
State Office of Rural Health to identify potential integrated sites, to develop initial 
criteria for site selection, and to identify individuals to serve on a working group. ORHP 
provided assistance to project principals in identifying potential Tribal entities that 
provided care to both Native and non-Native populations. In addition, all State Offices of 
Rural Health were surveyed to identify potential sites. 

In January 2004, ORHP convened a meeting in Denver, Colorado to bring project 
personnel from this study and another sponsored project study managed by the South 
East Alaska Regional Health Consortium (SEARHC). The SEARHC project objective 
was to study the qualitative and quantitative impacts of integrated health delivery model 
at two locations in SE Alaska. The primary purpose of this joint meeting was to identify 
topics and questions common to both ORHP-sponsored studies on Tribal/non-Tribal 
healthcare integration, and to the extent possible, agree upon wording and measurements 
for those topical questions to be shared by both teams. The results of this meeting as it 
pertains to this study included an identification of the work group, clarification of 
terminology, discussion and development of site selection criteria, discussion of study 
questions and scope of project. Project differences were identified and discussed. The 
SEARHC study is focused on internal operational histories at two Alaskan sites. Project 
staff will have direct access to all data required. The MSG study is focused on five sites 
nationally. Project staff will not have direct access to all desirable data. The analogy of 
this smaller study is a view from 5,000 feet versus the SEARHC study which is a view 
from 5 feet. The consensus of this group was that both projects would try to incorporate 
some questions that were worded identically in order to explore and possibly compare 
results. 

Two conference calls were held in February and March 2004 with the project's work 
group to finalize the study process, key informant interview questions, site selection 
criteria, and prioritize site visit locations. The key informant interview questions were 
divided into two groups, one for facility administrative and clinical personnel (Appendix 
1) and one for community members and patients (Appendix 2). The criteria for site 
selection included the following: 



18 



• Geographic - includes Alaska, hospital and clinics, diverse, rural and possibly one 
urban site 

• Type of funding - Community Health Center (CHC), Compact, Fee for Service 

• Length of integration - change of leadership/longevity important 

• Level of integration/ownership - scope of services - wider, diverse 

• Willingness to participate in project and possibly provide existing data 

Project principals had identified 13 sites that met the definition of integrated care. A 
matrix was developed for the work group that included information about each of these 
sites according to the criteria. The work group ranked each of these sites and directed 
project principals to contact sites according to the Ranking Matrix for Site Selection 
Process (see Appendix 3) until they found 5 sites willing to participate. After verbally 
agreeing to participate, each site signed a participation confirmation form. Appendix 4 
contains copies of all signed forms. Once all five sites were confirmed, project principals 
scheduled 2 day site visits and arranged interviews with various individuals at each site. 
These individuals included administrators, governing boards, key staff, community 
leaders, and health care users. 

The site visits were held, the interviews were completed, the results were documented, 
and this document was developed by project team members and submitted to ORHP. 
The work group will review and edit the final draft prior to submission to ORHP for 
completion of the contract. 

Limitations 

This report is a synopsis of five case studies and may not be representative of all the 
experiences of sites who have undertaken efforts to integrate services to both Native and 
non-Native populations. The process to gather information utilized key informant and 
focus group interviews, a qualitative versus quantitative process. The value of the 
information gathered through key informant and focus group interviews depends on the 
interviewer's ability to communicate the quality of the questions and selecting the 
appropriate participants. Participants were selected by the participating Tribal sites with 
guidance from the project principals to identify key stakeholders within each community. 
Selection was dependent on their willingness to participate and availability at the time of 
the site visit. 



19 



V. RESULTS 

The following is a summary of all five completed site visits and resulting interviews. In 
each case, the site, location, date of visit, interviewees, brief history and summary, and 
responses to interview questions are included. Under the section Responses to Interview 
Questions, key questions were listed along with their respective bullet point responses, 
which summarize the majority of answers to those questions. The responses to several 
questions were included in the brief history section. The key questions identified are 
assumed to capture the essence of this project. The original data with written responses 
on each questionnaire are available should detail be needed for additional documentation. 
Appendix 1 contains the actual key informant interview questionnaire. 



Site: 



Location: 



Date of Visit: 



Interviewees (19) : 



Site Visit Summary - Menominee Tribal Clinic 

Menominee Tribal Clinic 



Keshena, Wisconsin 

June 22-23, 2004 

Health Administrator 
Assistant Health Administrator 
Hospital Administrator, Shawano 
Medical Center 
Clinical Director (Medical Doctor) 
Community Health Nursing Director 
Diabetic Nurse Educator 
Mental Health Director 
Family Physicians (4) 
Nurse Practitioner 
Health Board Chairperson 
Business Manager (Tribal Council Member) 
Environmental Services Director 
Chief Pharmacist 
Dentist 

Menominee County Administrator (Native) 
Community Member - Native Patient 




Brief History and Summary : 

The Menominee Indian Tribe was the first Indian owned and operated Tribal health 
facility in the U.S. The Menominee Tribal Clinic opened in 1977 through the efforts of 
the Menominee Restoration Committee and the Menominee County Board of 
Supervisors, which were successful in obtaining a Congressional appropriation and Hill- 
Burton funds along with IHS dollars to construct and operate the facility. The Hill- 
Burton funding of $500,000 required the Tribe to provide access to services for non- 



20 




Natives. Once the Tribe demonstrated that it had complied with that requirement, the 
Tribe could then decide whether or not to continue serving non-Native patients. In 1989, 
the responsibilities under Hill-Burton were met and the Tribe decided to continue to 
provide services to non-Natives, although on a limited basis (fee for service). 



The mission since 1984 has been to provide 
quality, accessible and comprehensive health 
services. In 1989, the clinic pursued and was 
successfully accredited by the Joint 
Commission of Accreditation of Healthcare 
Organization (JCAHO). The Menominee Tribal 
Council oversees the credentialing of providers, 
the budget, and contracts. A Health Board of 
six Tribal members is appointed by the Tribal 
Council. The health board develops policies 
and procedures for the clinic and reviews 
services and facility development. 



The facility serves approximately 4,000 Indian Health Service Contract patients in a four 
county designated area. Total users are around 8,000 including 500 non-Natives (92 
percent Native patients; 8 percent non-Native). A sliding fee scale was implemented in 
2000 because the facility has one staff member assigned under the provisions of the 
National Health Service Corps, which requires open access on a sliding fee basis. 
Although the facility provides a sliding fee discount, it is rarely used. If a non-Native 
patient with no insurance or resources desires service at Menominee, they are required to 
pay $100 upfront at the time of service. This is primarily why only 8 percent of 
Menominee patients are non-Native. Additionally, the facility does not publicize or 
advertise their sliding fee availability. Some services, such as dental, are restricted to 
new Medicaid patients because of the high demand for care, current staffing levels and 
space constraints. 

The majority of non-Native patients are located off the reservation, the closest 
community being Shawano, 7 miles away, where family practice clinics and a critical 
access hospital exist and community resources may be available for those patients who 
lack access. 

The Menominee Tribal Clinic provides a full comprehensive array of outpatient services 
based on a public health model with a staff of 120 including six family physicians, five of 
which provide obstetrical care, and two nurse practitioners. 75 percent of their 
employees are Native Americans. Services include primary medical care, pharmacy, 
optometry, physical therapy, radiology, diabetes education, community health nursing, 
mental health counseling, nutrition counseling, wellness programs, emergency medical 
services, environmental services, women's personal health, audiology, and transportation. 

The facility was built in three phases including expansions and remodeling for a total of 
45,000 square feet. The clinic is operated under the provisions of Self-Determination, 



21 



P.L. 93-638, Title I. The clinic receives approximately $6 Million from the Indian Health 
Service, $5 Million from third party payers (4 percent Medicare, 29 percent Medicaid, 63 
percent Other insurance, 3 percent self-pay), and some State grants. 

Responses to Interview Questions 

What barriers were encountered initially and how did you overcome them? 

Barriers 

> Demand for services increased 

> Reservation is growing 

> Location: 7 miles from Shawano with a community hospital and clinics 

> Perception that quality wasn't good due to turnover and lack of access 

> Federal Torts Claim Act (malpractice coverage limited to beneficiaries) 

> Prejudice in coming on the reservation 

> Non-natives have to pay up front with no insurance 

> Pharmacy only available to Tribal members or patients that see Menominee 
providers 

> Multiple formularies required to meet regulations for pharmacy (340b 
program) 

How Overcame 

> Purchased additional malpractice insurance to cover non-Natives 

> Obtained JCAHO; increased perception of quality 

> Improved facility; upgrade equipment every 5 years 

How has access to care improved/changed? 

> Increased outreach 

> Improved services 

> Mainly for Natives (Native focus) 

> Additional patient care hours 

> Healthcare providers are involved in the community 

> Less access for uninsured compared to when the clinic was meeting Hill-Burton 
obligation 

> Less access for non-natives due to pricing schedules 



22 



What are the issues of integration today that are different than the initial stages? 

> Some non-Natives believe the process of accessing care is negative because of 
payment issues which creates a stigma and perceived discrimination in service 
and time 

> County Administration is all Natives whereas this was not the case at the 
beginning 

> Some prejudice continues to exist 

> Inability to hire more qualified Natives 

> IHS funding is limited; decreasing funding over time 

> Bill process for prescriptions is a hassle for non-natives 

> People may not know that the clinic is open to all people 

> More risks to tribe by being open to general population (malpractice/HIPAA) 

> More conflicts arise with pharmacy billing 

What are the advantages of integration and the one greatest benefit that has 
resulted from integration efforts? 

Advantages : 

> Sharing with others their communal/cultural beliefs 

> Creates common ground with the community 

> Can serve all family members; continuity of care for native and non-native 
members of same family 

> Lesson in humanity - Menominee are sharing people, not selfish 

> Accessibility to care and convenience (for all county residents) 

> Contributes to economic independence 

> Enhanced revenue helps provide expanded comprehensive care in an 
interdisciplinary environment; creates better facility; and develops programs 
to meet the needs of Native people 

> Ability to bill insurance provides more funding 

> Good for public relations 

> Quality of care is better 

> Increase resources for dental care (crowns, bridges, dentures) 

> Provides a diverse patient population 

One Greatest Benefit : 

> Ability to access public funding 

> Everyone benefits; no discrimination 

> Additional third party revenue supports expanded services 

> Overall better quality of care 

What are the disadvantages? 

> Non-Natives experience being a minority in a majority setting 

> Discriminates against non-Natives who don't have equal access for appointments 

> Less appointment time for Natives 



23 



> Greater liability risk to the tribe 

> Keeping up with the demand 

> Political issues can be difficult in thinking about the best approach that impacts all 
users 

> Too much demand that results in restricted care 

> Tribal perception that too many non-Natives use the facility 

> Attracts some patients who are considered less desirable 

> Dental care is limited to Native patients due to high demand 

> Contract health doesn't cover non-Natives - makes referrals for some patients 
(self-pay) difficult 

> Confusion on the types of services and prices offered to non-Natives 

> Assumption that clinic provides free health care 

> Non-natives see the other side of being a minority 

> Pharmacy is understaffed 

If you had the opportunity to do this again, would you? Why/Why not? 

All responded yes to this question. The following are their reasons. 

> Open is better than closed 

> Diversity makes us stronger, gives each other a chance to learn from each other 

> Decreases the tension between Natives and non-Natives 

> Be prepared for it 

> Conduct feasibility studies to plan for demand (staff, facility, scheduling) 

> Reach an understanding with other hospitals and regional clinics 

> Open is better than closed 

> All people should have the same opportunities 

> Benefits outweigh the liabilities 

> Clinic provides jobs for members 

> Helps the tribe become self-reliant 

What do you consider to be the key factors that other tribes should consider if they 
are contemplating integration? 

> Acknowledge there will be tension which is short term and manageable; will need 
a transition period 

> Make Tribal members aware; puts significant emphasis on education about the 
project 

> It generates greater income and less reliance on federal dollars 

> Manage the growth, be aware about negatively impacting services 

> Do a feasibility study and comprehensive planning 

> Obtain Tribal Council support as the first step 

> Collaboration and cooperation is important 

> Understand how demand for services impacts scheduling and staffing 
requirements 

> Establish clear cut rules for all users 

> Set measurable standards for care 



24 



> Understand that you cant do everything for everyone; must set reasonable 
expectations 

> Establish service area boundaries 

> Know the tribes health problems and establish a plan to address them 

> Don't be afraid to take the risk 

> Continuity of leadership in the governing body is important 

> Tribe should have the vision and commitment to improve health care as a priority 

> Establish strong financial and collection policies at the outset prior to opening to 
the public 

> Focus on recruitment and retention of staff 

> Don't be afraid to take the risk 

> Continuity of leadership 

> Study population base and demographics 

> Understand reimbursement 

> Develop a collection policy 

> Vision of strong health care and a commitment to quality 

> Culture must be ready 

> Plan for growth 

> Inform community and Tribal members 

> Develop clear policies for billing 

> Percentage of blood to be Native may change with growing number of mixed 
marriages 



25 



Site: 



Location: 



Site Visit Summary - Feather River Tribal Health 

Feather River Tribal Health 



Date of Visit: 



Interviewees (29) : 



Oroville, California 
June 28-29, 2004 





Tribal Leader/Board Member 

Health Center Board 

Group Interview at Board 

Meeting (12 Tribal Board 

Members and alternates 

representing three Rancherias) 

Executive Director 

Fiscal Officer 

Native Patient 

Medical Director 

Nursing Supervisor 

Diabetic Nurse Educator 

Social Worker 

Behavioral Health Services Director 

Grant/Facilities Manager 

Medical Clinic Manager 

Public Health Nurse/Quality Improvement Director 

Family Nurse Practitioner 

Physician Assistant 

Dentist 

Non-native patient 

Community Member - Native Patient 

Tribal Elder 







Brief History and Summary : 

The Feather River Tribal Health facility is 
located in Oroville, California and serves three 
Tribes: Berry Creek Rancheria, Mooretown 
Rancheria and Enterprise Rancheria. It had 
previously been part of a consortium of 14 
tribes in the North Sacramento Valley who 
operated and received services from the 
Northern Valley Clinic in Oroville. In 1992, 
Berry Creek and Mooretown broke off from the 
consortium and in 2003 Enterprise became the 
third member of what is now known as Feather River Tribal Health, Inc., an independent 
separate corporate 501(c)3 entity. Feather River Tribal Health has two locations; the 




26 




main facility in Oroville, which was built in 2002, and Yuba City, which opened in 1995. 
There are approximately 90 total staff, of which 
34 percent are Native. 

Currently, there are approximately 5,395 total 

active users, 55 percent Native and 45 percent 

non-Native. If insurance is available it is billed 

first for all patients. Approximately 50 percent 

of revenues come from IHS (638). Other 

sources include State IHS, grants, and third 

party payers (Medicaid 75 percent, private 10 

percent, and Medicare 15 percent). Feather 

River has a sliding fee scale, which represents 5 percent of third party revenues. 

Although the facility provides a sliding fee discount, it is rarely used. If a non-Native 

patient with no insurance or resources desires care at Feather River, they are required to 

pay at the time of service. This is primarily why only 5 percent of Feather River revenue 

is from sliding fees. The staff asserts that their facility is not "free" and that uninsured 

patients are encouraged to access the County clinic in town. Some services, such as 

dental and behavioral health are available only to Tribal members and are not open to 

non-Natives, primarily due to staffing and space availability. 

The Feather River facility provides a comprehensive array of outpatient services 
including: primary medical care, diabetic retinopathy screening, podiatry, dental care, 
diabetes education, community health nursing, mental health counseling, family resource 
center, maternal/child health services, nutrition education, women's health, massage 
therapy, and transportation. The clinic is operated under the provisions of Self- 
Determination, P.L. 93-638, Title I and is governed by a nine member board with three 
delegates from each tribe. A construction loan through the Bank of America and a loan 
guarantee through the United States Department of Agriculture (U.S.D.A.) were used for 
construction of new clinic. U.S.D.A. required services to all. 

Their mission: to elevate the health status of the American Indian people in our service 
area and all people in our communities to the highest level possible through a 
comprehensive system of preventive and therapeutic services. Also, to provide a broad 
range of culturally sensitive personal and public health services which will serve to meet 
our goal. Last year, the mission was changed to include non-Natives. 

Responses to Interview Questions 

What barriers were encountered initially and how did you overcome them? 

Barriers 

> Some grants specify Native patients 

> Providers have to track Native/non-Native 

> Fear of losing Tribal identity 

> Dental limited to Natives only due to overwhelming demand 



27 



> Desire for Natives first 

> Unable to offer pharmacy services at new site 

> Federal Torts Claim Act covers malpractice only for Natives 

> Relationship with hospital strained 

> Refusal to admit Native patients at hospital because physicians don't have 
privileges 

> Some concern that Natives would have to wait at new building 

> Outside providers 

How Overcame 

> Patient handbook 

> TV monitors in waiting room 

> Use local pharmacy under contract 

> Purchased malpractice gap coverage for non-Natives ($7,000) 

> Oroville Internal Medicine Group under contract to admit Tribal Clinic 
patients 

> Prove to outside providers that billing system works 

> Information provided for referral to specialists 

> Establish relationship with specialists 

How has access to care changed/improved? 

> Better for Natives and less for non-Natives 

> Improved services 

> Two tiered system that is of concern 

> Overall reduction in fees because of contractual arrangements for reduced fees for 
non-Natives 

> Natives have to wait longer for appointments 

> Greater capacity 

> Outreach improved 

> Podiatry added 

> More providers 

> Working with YMCA 

> Senior functions 

> Access to outside specialties with community 

> Best healthcare for tribes 

> New specialties (PULM, IM, PED) 

> Respect in community is good 

What are the issues of integration today that are different than the initial stages? 

> Much less concern about non-Natives accessing care that would impact Native 
care mainly due to being able to accommodate Natives 

> The billing of non-Natives is more businesslike; greater professional perception 
with stricter policies 

> Not much different 



28 



> Less time with providers 

> More cost conscious 

> Balance needs of Native/non-Native 

> Demonstrated that Native needs will be met 

> Communication and collaboration is ongoing 

> Tighter budget with prescriptions - CHS 

> Much less concern that seeing non-Native will impact access 

> Board and Administration has worked to build community access 

> No shows are 20 percent high 

> Some appointments are double booked to cover no-shows 

What are the advantages of integration and the one greatest benefit that has 
resulted from integration efforts? 

Advantages : 

> Expansion of services because of increased revenue 

> Fee reduction for primary care and lab 

> Easier to do health education and community based outreach 

> Philosophy toward health care; openness, prevention 

> Employment 

> Increase in staff and space 

> More inviting atmosphere with positive attitudes by staff and patients 

> Better quality and comprehensive care 

> Funding from Medicaid and Medicare 

> Comprehensive services 

> More jobs for Tribal members 

> All services under one roof 

> New facilities 

> Feather River has some of the best local providers 

> Reduction on fee for non-Natives (lab) 

> Broader community support 

One Greatest Benefit : 

> Access to care 

> Variety of payor sources 

> Additional third party revenue supports expanded services 

> Overall better quality of care 

> New facility 

> Increases the Tribes options 

> Public relations between Natives and non-Natives 

> Clinic specifically can focus on Native diseases 

What are the disadvantages? 

> Perception that it may be more difficult for non-Natives to access care 

> Cant subsidize pharmacy as easily as other services 



29 



> Non-Native access to care for all services not guaranteed 

> Wait time for Natives 

> Greater financial burden and more oversight needed to monitor the program 

> Balance 

> Demand for services 

> None 

> Access 

> More bills with new building 

> Indian household originally received free care, then 25 percent discount on their 
bill 

> More business like 

> Stricter policies 

> BHS/Dental 

> No access 

> Finding funding 

> Variety of payers 

> Access, is it open to Natives? 

If you had the opportunity to do this again, would you? Why/Why not? 

All responded yes. Reasons are listed below. 

> Open system is better for the entire community 

> Being rural we need to serve everyone yet act as a business 

> Great achievement to Native and non-Native people 

> Employment boost to the community 

> Best mechanism to keep independence 

> Care for others and take care of our own 

> An achievement for W/NS 

What do you consider to be the key factors that other tribes should consider if they 
are contemplating integration? 

> Hire community people as much as possible 

> Hire strong experienced management, quality staff 

> Establish appropriate Board roles; Board needs to have full authority to govern 

> Operate the clinic as a business 

> Talk with other tribes, share information 

> Open access as much as possible that is supportable financially 

> Market what you do 

> Research alternative funding sources while increasing efforts to increase third 
party revenue 

> Reach out to the community resources and be visible 

> Look at cultural diversity of the population you wish to serve 

> Have all policies in place, access identified so it is clear 

> Front desk PR and education is very important 

> Eligibility for many grants 



30 



> Have your ducks lined up 

> Keep providers out of the politics and let them do health care 

> PR across the board 

> Establish teamwork philosophy 

> Keep politics out of it; stick to the policies and procedures 

> If doing a project with other tribes, make sure they can get along and understand 
the issues 

> Assess the competition; do a needs assessment; understand the business of health 
care 

> Be willing to change, provide as much care as possible and don't forget the elders 

> Look at grants for start-up 

> Get the word out 

> Direct access - so it is open to all 

> Consider area 

> Involve community 

> Determine if Indian/Non-Indian households treated the same 

> Policies need to be clear 

> Hire from tribe (watch confidentiality) 

> Board has to operate as business 

> Public location 

> Funding sources 

> General membership 

> Strong Board 

> Support and approval needed 

> Education with community 

> Good staff 

> Tribally led organization 

> Will have focus/control plan for diversity of care 



31 



Site Visit Summary - Benewah Medical and Wellness Center 
Site : Benewah Medical & Wellness Center 

Location: Plummer, Idaho 



Date of Visit: 



Interviewees (19) : 




July 28-29, 2004 

Executive Director 
Board Members (3) (Native) 
Board Members (2) (Community 
representatives, non-Native) 
Elder 

Accounting Manager 
Maternal Health Nurse 
Family Physician, Medical Director 
Community Health Director/Nurse Practitioner 
Patient 

Registered Nurse 
Chief Financial Officer 
Quality Improvement Manager 
Medical Coder 
Pharmacist 
Community Health Nurse 



Brief History and Summary : 

The Benewah Medical and Wellness Center is 
owned and operated by the Coeur d'Alene Tribe 
and is located in Plummer, Idaho. For many years 
the Tribe had a satellite clinic as part of an IHS 
multi-Tribal Service Unit. In 1990, the Tribe 
entered into a P.L. 93-638 contract to establish itself 
as an independent administrative Service Unit. The 
first facility opened in mid 1990 and initially began 
providing comprehensive care to both Native and 
non-Native patients. The first major expansion 
occurred in 1994. Also during that same year, the Tribe received HRSA 330 funding as a 
Community Health Center to address the uninsured service area population. In 1995, the 
Tribe entered into a Title V Self-governance Compact with IHS. In 1998, the Tribe 
opened the Wellness Center, a significant effort to focus on prevention and rehabilitation, 
located two blocks from the clinic. 

There are approximately 3,733 Native active users out of nearly 8,000 total users. In 
terms of utilization, approximately 47 percent are Native and 53 percent non-Native. The 
sources of revenue include 50 percent IHS, 20 percent from a CHC grant, 25 percent 




32 



from third party payors, and 4 percent from wellness center activities. All Natives are 
treated. Non-natives are charged a nominal fee of $10 at time of service. The clinic has 
always offered a sliding fee discount for uninsured patients in specified area code region. 
It is not a free clinic. The facility has a service area population of 8,000 although 
numerous patients travel great distances, from three states, for service. There is currently 
125 staff, most of which are full time. With the strong growth in demand for services, the 
facility has long outgrown its capability of meeting 
future needs. Plans are underway to construct a new 
building within the next three years. 

A variety of services are provided including: primary 
medical care, physical therapy, radiology, pharmacy, 
podiatric, youth program, mental health counseling, 
aquatics, community health, laboratory, 
fitness/wellness center, and dental. The services are 
open to all except non-U. S. Indians. 

The mission is to provide primary care, holistic healing, preventative care, and wellness 
promotion to all members of the community as intended by the creator. The Tribal 
Council oversees legal issues and resolutions. The Tribal Health Board is the governing 
board for the Center and consists of seven members appointed by the Tribal Council and 
2 members appointed by the City of Plummer. 

Responses to Interview Questions 

What barriers were encountered initially and how did you overcome them? 




Barriers 

> Focus should be on Natives - owned by Tribe 

> Limited number of exam rooms 

> Lack of transportation 

> Poverty 

> High demand for medical and dental 

> Waiting times 

> Construction costs to be divided 

> Pharmacy formulary regulations 

> Complicated billing 

> Indian preference in hiring 

> Reimbursement declining 

> Grants are more competitive 

> Geographically isolated 

> Some discrimination; looked upon as a Free Clinic 

> Land price was high 

How Overcame 

> Natives tend not to share income information 



33 



> Working on networks and collaboration 

> Goal 50 percent Native 40 percent non-Native 

> Provide quality services 

> Health career promotion at schools 

> Converted to open access scheduling and decreased wait time for physicals 

How has access to care changed/improved? 

> Improved services; many choices 

> Sometimes more difficult to get an appt because of the growth 

> Restricted access for some services 

> Better with same day appointment system 

> Lack of space limits some access 

> More specialty care; reduction in travel to see outside providers 

> Longer waits, but more choice 

> More expansion due to demand 

> 50 percent of registered patients are Native, 60-70 percent of encounters are 
Native 

> Medical staff is good 

> Same day appointments 

> Pharmacy/physical therapy are local 

> Better communication between medical and nursing 

What are the issues of integration today that are different than the initial stages? 

> Some Tribal members still have animosity about being open to the public 

> Changing patient care access for medical and dental 

> Space is an issue because of the unanticipated growth 

> Much more complexity than in the beginning 

> Requires organization to be aggressive in collaborative efforts and seeking 
additional funding 

> Some Tribal members feel clinic was built for them and they should have direct 
access 

> More preventive care 

> Not everyone knows how to use open access 

> Mammography 

> Wellness 

What are the advantages of integration and the one greatest benefit that has 
resulted from integration efforts? 

Advantages : 

> Opened up job opportunities/careers for Natives and community members 

> Have provider choices 

> Stronger bridge between Tribe and community 

> Attracts providers who are more committed/increased retention 



34 



> Medical and prevention focus-took the best of both worlds 

> Increased prevention awareness 

> Ability to leverage resources/economies of scale 

> Increased funding from multiple sources 

> Improved standards of care 

> Personal touch 

> Caring providers (not like IHS) 

> More services/higher quality 

> Leverage resources for more services 

> More opportunities as a CHC 

> Integration is inviting to grantors 

> Bring community together 

> Decreased prejudgment 

> Leveraging resources 

> More services, better services 

> Local immediate care 

> Access for non-Natives 

> Eligibility of grants 

> High quality services 

> Outreach from tribe to community 

One Greatest Benefit : 

> Expansion of care and services because of increased revenue 

> Access to care 

> Medical access for sliding fee users 

> Opportunity for employment for Tribal members 

> The fact that the Tribe recognizes the community need as well as their own 

What are the disadvantages? 

> Growth and size inhibits family feeling due to mgmt/leadership philosophy and 
policy changes 

> Staff struggle to keep up with the volume of patients which impacts morale 

> Sometimes you have to restrict services 

> Have to address bad debts/collections with people you might know 

> Management of the facility gets more complex 

> Tribal and community expectations are unrealistic 

> Some competitiveness from external providers as the clinic continues to be very 
successful 

> Politics can be a major challenge due, in part, to the economic visibility 

> Multiple reporting requirements for all funding sources 

> Difficult to change internally at times especially moving away from IHS systems 
that are not suited for this kind of environment 

> CHC Bureau grant promotes "see all patients" conflicts with non-paying patients 

> Job opportunities 

> Complexity of healthcare issues (mental health, substance abuse, diabetes) 



35 



> Difficult to explain sliding fee scale 

> Administrative side hasn't kept up with volume 

> Keeping up with demand 

> Decreasing cash 

> Prescriptions limited to patients, but not available to local Veterans 

> Financial/accounting 

> Space; keeping up with demand 

> Regulations in pharmacy 

> Collection issues with non-Natives 

> Complexity of pharmacy; fairness with different formulary 

If you had the opportunity to do this again, would you? Why/Why not? 

> Yes, great system; everyone wins 

> Yes, could not have what we have without the same setup 

> Yes, with good director 

What do you consider to be the key factors that other tribes should consider if they 
are contemplating integration? 

> Have an open mind-be willing to have disagreements 

> Strong leadership & management that is qualified with cultural sensitivity is 
critical 

> Board that is composed of both Native and non-Native representatives 

> Have community meetings/input throughout the year 

> Operate as a business as a foundation 

> Establish a clear mission and be prepared to commit resources to accomplish the 
mission 

> Must have adequate software for billing, collections, financial management 

> Systems need to be integrated as much as possible 

> Include Behavioral Health program that has both mental health/chemical 
dependency 

> Establish pride in the facility from the start 

> Be prepared for expansion 

> Go slow and prepare well 

> Health Board that is properly trained 

> Become a HRS A Community Health Center because of the benefits 

> Balance between business and cultural sensitivity 

> Employee commitment to vision 

> Have property secured 

> Long-range planning 

> Integrated health base 

> Community meetings 

> Meeting structure 

> Good staff, professionally qualified 

> Governance to allow good decisions without political interference 



36 



> Director needs to hold his own 

> Do it the "white way" (financial/business) yet keep cultural values 

> Business side must be in place, financial diversity 

> Good policies for employees 

> Cultural sensitivity 

> Good grant writer 

> All populations should be aware of available services 

> Strive to serve both equally 

> Involve entire community in planning 

> Funding can be challenging in poor counties 



37 



Site Visit Summary - Montezuma Creek Community Health Center 

Site : Montezuma Creek Community Health Center 

Montezuma Creek, Utah 



Location: 



Date of Visit: 



Interviewees (20) : 



August 11-12, 2004 

Tribal Member/Board Chair 
Chief Executive Director 
Chief Financial Officer 
Nursing Supervisor 
Elder Native Patient/Community 
Member 

Medical Director (Family Physician) 
Social Worker 
Physician Assistants (3) 
Family Physicians (2) 
Pharmacist 
Dentists (2) 
Dental Resident 

Staff Development Coordinator (RN) 
Non-native patient/Community Member 
Community Member - Native Patient 
Community Member 
Human Resources Manager 




Brief History and Summary : 



The Utah Navajo Health System is a private, non-profit 
501(c)3 corporation that oversees the Montezuma 
Creek Community Health Center. The health center 
began operations under the UNHS umbrella in January, 
2000. It is a Tribally operated organization under the 
auspices of P.L. 93-638. The 638 contract was 
implemented in mid 2002. The health center also 
received funding as a HRSA 330 Community Health 
Center grantee in 2001 . 



Prior to UNHS being established, health care in the Montezuma Creek area was 
inconsistent, challenged with financial difficulties and wrought with litigations. Utah 
Navajo Health System evolved from a single service agency providing care for patients 
with diabetes to an agency providing comprehensive care to 1 0,000 community members 
in the service area. The Navajo Tribe, communities in the service area and County 
representatives were instrumental in creating and supporting this new model of care. 




38 



The service area includes the Utah strip of the Navajo Nation and the underserved 
community of San Juan County. There are 7,435 registered Indian patients in FY 2003. 
The organization now has three sites; the main clinic at Montezuma Creek and two 
satellites; one at Blanding (57 percent of Blanding County is Native), Utah and the other 
at Navajo Mountain. There are approximately 90 staff serving 75 percent Native and 25 
percent non-Native users. All the facilities are rural and frontier. 

Sources of funding include IHS (48 percent), Medicaid (30 percent), Medicare (8 
percent), and other private insurance (14 percent). Services are offered on a sliding fee 
basis. Tribal members are also encouraged to apply, but are reluctant to share financial 
information and assume that IHS covers all costs. Sixty-five percent of non-Natives are 
at sliding fee scale and the rest are covered by third party insurance. Many of the patients 
who access this facility only speak the Navajo language. Translation services as an 
indicator of cultural sensitivity are a significant aspect of this organization. 



Services provided include: primary medical care, 
radiology and ultrasound, mammography, 
densitometry, podiatry, laboratory, dental, health 
education, mental health counseling, nursing 
home placement, pharmacy, 

obstetrics/gynecology, immunizations, nutrition 
education, home visits, radiation exposure 
screening and education, and vision screening. A 
Native Board of Directors governs them. The 
board members represent all communities served 
and are users of the facility. One board position 
is paid as a Tribal liaison. 




Their mission is to make a difference in the quality of life for all community members by 
providing a high quality, comprehensive primary and preventative health care in a 
culturally and linguistically competent manner while maintaining fiscal viability. 

Responses to Interview Questions 

What barriers were encountered initially and how did you overcome them? 

Barriers 

> Tribal politics 

> Fast growth - space issues 

> No support from Indian Health Services 

> Lack of experience with non-profit boards 

> Use or enrollment to Medicaid 

> Coordination of dollars due to regulations 

> Compliance coordination and meeting growth goals 

> Many no-shows 



39 



How Overcame 

> Patient and tribe education 

> Board development 

> Videos in waiting room 

> JCAHO provided structure for continuous quality improvement 

> Committees 

> Staff education/orientation of reporting requirements 

> Walk-ins allowed in the mornings 

> Communication among staff difficult with fast growth 

> More non-Native staff at Blanding 

> Focus group at Blanding is multi-disciplinary 

> Education of Tribal board - workshop held on 63 8 self-determination for 
Navajo Council 

> None - everyone treated the same 

How has access to care changed/improved? 

> Improved services; many choices 

> Better providers 

> Less wait times 

> Elders will now seek care that otherwise would go without 

> Dramatic improvement in access for indigent people 

> Increase in hours of service 

> More options to work with to meet the needs of the population 

> Able to provide a higher level of service (dentures, root canals) 

> Very good 

> One elder, a regular user, brought her sister here from 70 miles for the first time 

> Access expanded to uninsured in the community 

> Discounted prescriptions available to non-Native patients 

> More female providers 

What are the issues of integration today that are different than the initial stages? 

> Non-Natives now prefer to come here and will actually drive farther than Natives 

> Not many non-Natives come here but they are welcome 

> More customer friendly; getting away from IHS mentality 

> Patients seem to take their care more seriously 

> Some outside providers view organization as competition 

> Better PR in the waiting room 

> Perception of non-Natives that they get treated differently 

> Improved training; staff works well together - family orientation 

> More employees now; HR Manager needed 



40 



What are the advantages of integration and the one greatest benefit that has 
resulted from integration efforts? 

Advantages : 

> Providing quality adequate health service to everyone and that standards are 
included and required 

> Increased services 

> Opened up job opportunities/careers for Natives and community members 

> Speak the language including some of the providers 

> Less wait time 

> Staff is trained and community education is part of the care 

> Greater accountability all around 

> Financial stability 

> Community perception assists others in their staff recruitment as well 

> One stop shop model 

> Integration of all beliefs within the Tribe 

> Diversity of patient population 

> Convenience 

> Integration of traditional, Western and Navajo church in treatment 

> Access to local healthcare for Navajo and Ute 

> Dental, behavioral health and specialists available to everyone 

> Breakdown racism by providing access to everyone 

> Access to primary care, not just emergency rooms 

> Preventive focus with diabetes 

> Podiatrist added 

> Funds to recruit and retain medical staff 

> Funding diversity to augment contract health services 

> CHC has model for success; technical assistance from HRSA 

> Quality and adequate healthcare 

> Only sliding fee scale in the County 

> Expanded care with Mammography and immediate testing 

> Local jobs 

> Private clinic approach to customer satisfaction; employee accountability 

> Work with patients to provide the preventive service 

> Convenience 

> Immediate care for traumas 

> Benefit for uninsured 

> Nice staff - courteous 

One Greatest Benefit : 

> Expansion of care and quality services because of increased revenue 

> Equal treatment for all the community 

> Progressive system of care that never would have occurred 

> Care for rural residents 



41 



What are the disadvantages? 

> Some of the regulations can be cumbersome 

> High growth results in space constraints 

> Increased demand for services can overextend providers and staff 

> Vertical management style may leave out input from Tribal members that have 
little representation at the management level 

> Some limitations in treating more serious illnesses 

> Politics of the Tribal organization 

> Potential to over extend financially and physically if you grow too fast 

> People don't like change 

> No disadvantages 

> Funding could change 

> States determine Medicaid rate 

> All the requirements and reporting with two channels of funding 

> Accounting is a challenge 

> Fast growth 

> Politics in Navajo Council - 638 contract is a pilot project 

> No disadvantage for delivery of healthcare 

> Preventive focus for patients saves lives and keeps money in the long run 

> Expansion is rapid - hard to keep ahead on procedures 

> Lack of sharing records across IHS facilities 

> As demand increases - need more providers 

If you had the opportunity to do this again, would you? Why/Why not? 

> Yes, people would not have as good a health care without it 

> Yes, because of access to all services and the improvements made compared to 
the other system 

> Yes, it meets the needs of the people 

> Yes, overwhelming 

> Many improvements with appointment availability 

> Billing has improved 

> Better quality of care 

> Extended hours 

> Providers regard UNHS higher than Indian Health Service 

> Improvements in healthcare 

> Caring staff 

> Absolutely; different approach helps care 

What do you consider to be the key factors that other tribes should consider if they 
are contemplating integration? 

> Provide constant public education and information 

> Include Tribal liaison in your contract to fund a strong Tribal rep 



42 



> Strong Board that is dedicated to the organization and understands the needs 

> IHS will never be adequately funded 

> Access other types of funding like CHC's 

> Must understand financing and reimbursements 

> Make it a priority to have excellent service 

> Go after other resources for funding; learn all you can 

> Indian staff development is important 

> Hire qualified staff that have the needs of the people as a priority 

> Don't allow IHS to get in your way 

> Obtain community and Tribal approval 

> Establish environment that is friendly, not too many rules and barriers to care 

> Patient care must be #1 ; focus on quality 

> Visit other models; obtain assistance from a variety of resources 

> Be proactive and aggressive in pursuit of resources 

> Need visionary and enthusiastic people 

> Board must have autonomy within Tribal administration to oversee the facility 

> Plan to address nepotism, personnel issues by policy; strong PR system 

> Must be aware of obstacles in providing equal access to care 

> Hire from both populations 

> Hire a solid grant writer who can assist in raising funds 

> Plan for an operational reserve 

> Trust between board and administration 

> Hire people with a vision and dedicated staff 

> Teach their own; promote from within 

> IHS won't ever be adequately funded; integration elevates healthcare access with 
other funding such as CHC 

> Key person from tribe and strong board 

> Patient care is number 1 

> Find good providers and staff 

> Be goal orientated; use data 

> Local strong and knowledgeable board of directors 

> Understand healthcare needs; experience with local healthcare 

> Strong managerial organization 

> Empowered staff that are committed 

> Diversity sources of funding 

> Build operational reserve 

> Communicate well with community 

> Integration is harder on a reservation; UNHS is a boarder town 

> Visit models; be proactive 

> Develop policy to avoid nepotism 

> Keep it open to the public from the beginning 

> Hire native and non-Native 



43 



Site Visit Summary - Norton Sound Health Corporation 

Site : Norton Sound Health Corporation 

Location : Nome, Alaska 

September 8-9, 2004 



Date of Visit: 



Interviewees (11): 



Tribal Member/Board Chair 
President/Chief Executive Director 
(non-Native) 
Chief Financial Officer 
Director of Village Health Services 
Behavioral Health Director 
Physician Assistant 
Dentist 
Tribal Leader 

Board Member - non-Native Community Leader 
Community Member - Native Patient 
Tribal Elder - Patient/Board Member 




Brief History and Summary : 

The Norton Sound Health Corporation was formed in 1 970 as a non-profit consortium of 
20 tribes of the Bering Strait region of northwest Alaska in order to assume ownership of 
the hospital that had been previously owned and managed by the Methodists. The 
hospital had been losing money for many years and was not open to Natives. Natives had 
to travel to Kotzebue for health care, which was over 150 miles away by air and not 
accessible by road. The Health Corporation wanted to treat all patients as well as have 
community representation on their Board. Currently, there are two permanent 
community representatives, an at large non-Native position and a Nome City Council 
representative. There are 24 Board members representing 15 villages and 20 tribes 
within the Norton Sound service area. The service area is approximately 1 1,000, 85% of 
whom are Native overall, with 50% Native in Nome. 

The hospital in Nome was designated a critical access hospital in November, 2003. It has 
19 beds, an outpatient clinic, basic inpatient services and allied health. In 2003, the 
hospital has 566 admissions (ADC 4-6), 2,982 emergency patients, and 102 births. The 
Corporation also owns a 15 bed nursing home located in Nome which has a high 
occupancy rate and is primarily for elders from the villages. 55% of health users are 
Native and 45% non-Native. Norton Sound has made it to the Indian Health Service 
construction priority list with other funding sources and has begun the planning for a new 
hospital scheduled to break ground in 2006. 



44 



In 2002, the Corporation received HRSA Community Health Center funding for all 15 
village clinics. Funds are used to provide salaries, travel and training for the Health 
Aides and other staff in each community. 

Services provided include: primary medical care including obstetrics, in-patient acute 
care, emergency department and services including air evacuations, radiology and 
ultrasound, mammography, physical therapy, podiatry, laboratory, dental, community 
health services, village health services, mental health counseling, nursing home, 
pharmacy, optometry, maternal/child health, audio logy, social services, elder care, 
nutrition education, and environmental services. The Corporation has 425 permanent 
staff and 75 seasonal staff. 

Sources of funding include IHS (51%), third party patient revenues (31%), State and 
Federal grants (22%), and other (6%). A sliding fee scale has been in place for several 
years. 

The Corporation operates under a P.L. 93-638 Self-Governance Compact. Their mission 
is to provide quality health services and promote healthy choices within our communities. 

Responses to Interview Questions 

What barriers were encountered initially and how did you overcome them? 

Barriers 

> Some services are limited for non-Natives such as travel expenses to 
Anchorage and visits with specialists unless there are appointments available 

> Geographic limitations 

> Providers working in Village clinics may not treat everyone the same; family 
members receive different treatment 

> Perception that Anchorage services are better because it's bigger 

> Surgical procedures aren't available in Nome 

> Village clinics have to collect money for services from non-Natives 

> Counseling services can't be billed unless provider has a Master's and is 
licensed 

> Sometimes Tribal politics become a factor and certain tribes want more 
representation, less community representation 

How Overcame 

> Pediatric dentists visit Nome and villages 1-12 weeks a year 

> JCAHO accreditation 

> Planning for new facility 

> Non-natives are board members to keep communication with City 

How has access to care changed/improved? 

> Improved because of additional funding 



45 



> Many more services 

> More staff 

> Major village clinic expansion; services now in all villages 

> Much better with physician assistants 

> More training for Health Aides 

> Comprehensive services in Nome for Natives and Community 

What are the issues of integration today that are different than the initial stages? 

> Decrease in Indian Health funding puts pressure on 3 r party and other sources of 
revenue 

> Board is integrated which is very positive 

> Some still see the hospital as a 'band aid' station-difficult to overcome past 
perceptions 

> More services offered 

> Some conflict if non-Natives feel that IHS provides for Natives 

> Non IHS staff at NSHC is better; positive attitude 

What are the advantages of integration and the one greatest benefit that has 
resulted from integration efforts? 

Advantages : 

> Build rapport with the community 

> Better continuity of care 

> Open to the community; greater access 

> Economic benefit for non-Natives due to the isolation of the area 

> Opportunity to maximize resources 

> Longevity and quality of staff 

> Expanded services 

> No competition 

> Keeps people at home working for their own Tribe 

> Integration of care is good 

> New villages clinics 

> Society should be integrated 

> No discrimination 

> All receive same quality of care 

> Emergency services provided locally 

> More support for facility by billing third party insurance 

> Broad support for projects - locally and with Denali Commission 

> Helping others is part of values 

> Healthcare is essential 

> Harsh environment builds camaraderie; competition in the region isn't 
practical 

> Expanded services 



46 



One Greatest Benefit : 

> Improved community relations 

> Financial 

> Better quality of care and access to care 

What are the disadvantages? 

> Non-Native access to specialist is difficult with no options for financial assistance 

> Access to same resources are not equal 

> Fear of change 

> Cant offer all specialty care to non-Natives 

> Appointments prioritized for Natives especially in dental 

> Strong demand creates continued constraints of some services 

> If governance not structured properly from the start, Tribal needs could become 
secondary 

> Could be geared towards non-Tribal needs if not structured properly 

> Tribal people don't put themselves forward and tend to sit silently 

> Some competition could be healthy 

> Difficult to serve all Villages with limited access and small population 

> Non-natives have limited access to specialists in Nome 

> Dental access is at a high level of demand; priority for non-Natives 

If you had the opportunity to do this again, would you? Why/Why not? 

> Yes, no question this is the best thing we did 

> Yes, it's important to expand the capability of your health program 

> Yes, by all 

> Improvements in local healthcare 

What do you consider to be the key factors that other tribes should consider if they 
are contemplating integration? 

> Obtain Council resolution to approve and support the health care mission 

> Know the opposition and how to address their issues 

> Assess the competition, if any, and fill a niche 

> Have a least one Board seat from the community 

> Take care of Native beneficiaries and understand the financial implications 

> Identify how the dollars will benefit Natives 

> Establish a strong business office and procedures with no former Indian Health 
Service staff 

> Provide clear expectations about costs of services 

> Educate Tribal members as to the value of non-Native care 

> Identify services and quality measures that will be in place 

> Define rights and responsibilities 

> Establish a clear complaint process and expectations of service 



47 



> Establish strong governance system, do adequate planning and have consumer 
advocacy boards 

> Hire qualified experienced staff and good management 

> Be careful about grant supported services 

> Know that Indian Health will not have sufficient funding; seek other sources of 
support 

> Hire grant writer 

> Take the risk and meet the challenge 

> Clear goals, objectives, core values and mission 

> Follow policies consistently 

> Place people on Board for the right reasons 

> Educate non-Native users about Native benefits 

> Set appropriate fee structure that is adequate to meet costs 

> Develop a good business plan 

> Build a reserve account for unexpected events 

> Maximize billing of third party payers 

> Staff should treat all people equally 

> Be respectful 

> Look at whole person; use an interdisciplinary approach 

> Need good data and software 

> Look at fee structure 

> Provide quality services 

> Implement a merit based system for performance review of staff 

> Keep quality high 

> Important for non-Native board members to provide community input 

> Educate members as to how the extra revenue from non-Natives dollars will 
benefit Natives 

> Take care of Native beneficiaries and understand the financial implications of 
opening the doors 

> Tribal members need to exercise power to make decisions 

> Be sure to provide services that people ask for 

> Structure governance so that Tribal needs aren't lost especially in villages 

> Maintain zero tolerance for unequal treatment 

> Know core values of tribe 

> Could be overwhelmed by uninsured 

> Conduct a cost/benefit analysis 

> Check out opposition - talk with private health community if present 



48 



VI. SUMMARY 

The following summarizes major points about initial barriers to integration, issues today 
that are different than initial stages, advantages of integration and one greatest benefit, 
disadvantages of integration, improvements or changes to access to care, key factors that 
other tribes should consider if contemplating integration, and whether they would pursue 
integration if given the opportunity to do it again. 

Barriers: 

• Increased growth/demand for services 

• Declining public perception regarding quality of services 

• Limited services available to non-Natives 

• Fears: loss of Tribal identity, loss of access, loss of focus on Natives, loss of 
revenues 

• Lack of IHS support and technical assistance in forming integrated models 

• Lack of leadership experience (administration/board) 

• Coordination of dollars due to regulations 

Current Issues: 

• Perceived discrimination by non-Natives 

• Inability to hire Natives 

• Difficulties in balancing the needs of both populations 

• Much more complex in terms of management/administration 

• More liability risks to tribes 

Advantages: 

• Enhanced sharing/respect for diversity 

• Increased continuity of care 

• Decreased prejudice 

• Increased access for all 

• Increased economic independence 

• Diversified funding sources leads to more comprehensive care 

• Increase public relations and community support 

• Increased quality of care 

• Increased resources to support service expansions, staff, and new facilities 

• Increased choice 

• Enhanced provider recruitment and retention 

One Greatest Benefit: 

• Diverse funding stream leads to increased resources 

• Increased resources leads to improved quality and access to care 

• Increased quality and access leads to improved community/public relations 

• Improved public relations leads to increase utilization 

Disadvantages: 

49 



Two tiered system discriminates against non-Natives 

Increased liability risk to tribes to treat non-Natives (malpractice/HIPAA) 

Decreased access to Natives (appointment time access) 

Multiple reporting requirements 

Management complexities 

Cumbersome regulations 

Billing/collection knowledge requirements and issues 

Structure could lose focus on Native needs 

Stricter policies/more businesslike operations 

Access Improvements/Changes: 

Improved variety of services 

Local access to specialty services 

Increased choice of providers 

Greater capacity 

Increases hours of service 

Less wait time 

Longer waits but more choice 

Increased outreach efforts 

Better and more providers 

More training opportunities for staff 

Increased respect 

Key Factors if Contemplating Integrated Services: 
Strong continuous leadership 
Clear vision and realistic expectations 
Anticipate tensions; educate all parties; develop plan 

Involve all parties in planning meetings; inform community and Tribal members 
Integrate staff and board 

Focus on infrastructure by having policies in place, businesslike operations, 
training for staff 
Study/explore funding sources 
Hire a grant writer 
Build financial reserves 
Reduce politics and increase teamwork 
Hire good staff 
Provide high quality services 
Focus should be on the patient needs 
Do a feasibility study and comprehensive planning 
Understand third party payer reimbursement (including Medicaid and Medicare) 

Would Repeat: (all would pursue integration again) 

• Integration is better for everyone 

• Diversity makes us stronger, decreases tension between Natives/non-Natives 



50 



• Benefits far outweigh the liabilities 

• Best mechanism for maintaining/improving independence/self-reliance 

• Many improvements in healthcare made possible due to diversified funding 
sources 

Many of the interviewees stated that offering integrated services was the right thing to do 
because sharing is part of their value structure. At sites that were remote, such as Norton 
Sound Health Corporation, Benewah or Montezuma Creek, the interviewees noted that if 
the Tribe didn't open their services to non-Natives, there would be no local access to 
health care for non-Natives. In Nome, the nearest healthcare would be 500 miles away in 
Anchorage if the tribe didn't share services. 

All of the health care administrators and board members indicated that the financial 
benefit by billing third party payers and accessing grants through integrated services 
allowed the clinics to hire additional providers, access specialists, offer preventive care 
services, and upgrade facilities. The quality of care increases as a result of IHS funding 
alone would not cover basic primary care or contract health services. A few of the tribes 
indicated that the revenue from third part}'- payers covered contract health services that 
were over the IHS allotment. 

All of the sites offered a sliding fee scale for uninsured patients; however, it was 
promoted and more widely utilized at the sites with Community Health Centers 
(Benewah, Nome and Montezuma Creek). The other sites were concerned about keeping 
up with demand for services and wanted to keep appointments available for Native 
patients that they indicated were the priority. 

Integration has significantly benefited these Tribal entities in terms of improvements in 
resources (diversified revenue streams/increased revenues/staffing/facilities) which has 
led to improved quality of care, more comprehensive care, and enhanced public 
perceptions. The path to integration was also fraught with tension and challenges of 
change that were overcome with 1) strong, visionary leadership, 2) the use of an inclusive 
process that involved representatives from both Natives and non-Natives, 3) a recognition 
that education and information must be shared openly with all involved, 4) a thorough 
planning process to identify community needs, explore funding options and 
rules/regulations, 5) infrastructure improvements including adequate skilled staff (e.g. 
management, clinical, grant writer, etc.), staff training (billing / collection processes), and 
adequate computer resources and IT support, and 6) clear, reasonable expectations of 
outcomes. 

All participants at the Tribal sites enthusiastically embraced the decision to integrate their 
services. When asked if they would repeat their integration efforts if given the 
opportunity, all of them expressed without hesitation, they would definitely pursue that 
option. Tribal health systems around the country who are operating under the provisions 
of self-determination Contracting under P.L. 93-638 or Self-Governance Compacting 
under Title V, have a unique opportunity to enhance their health care by learning from 
this study that there are numerous benefits and challenges that are worth exploring. 



51 



Issues/Recommendations: 

The statement earlier this year by IHS that the Federal Tort Claims Act would not cover 
malpractice claims for non-Natives was mentioned by 3 of the 5 sites as a potential 
barrier. The sites purchased additional malpractice insurance to cover any potential gaps, 
although the administrators weren't sure if it was actually needed. 

The reporting regulations for IHS and the Bureau of Primary Health Care are duplicative 
yet utilize different standards. Many of the sites indicated that the RPMS, the IHS 
software for tracking patients and services, was cumbersome and didn't work well with 
an integrated clinic. 

Pharmacy regulations and costs were mentioned frequently by providers, patients and 
administrators. Pharmacy formularies are different for Community Health Centers with 
the 340(b) program, IHS, 3rd party payers, and cash patients causing some of the 
pharmacies to have 3 different formularies. Two of the clinics had limited pharmacy 
services to clinic patients only. Community members at the non-community health 
center sites often noted that the cost of pharmaceuticals was prohibitive for non-Native 
patients. 

Community Health Center funding specifically for Native sites was cited by a few 
administrators and board members as an incentive for integrated Tribal clinics to apply 
for 330 grants. They noted that there the grants are highly competitive and many were 
not aware of technical assistance resources for grant applications through state Primary 
Care Associations. We also found that they sites with critical access hospitals were not 
aware of the Rural Hospital Flexibility Grant Program Technical Assistance and Services 
Center. The clinic leaders noted that technical assistance would be helpful in forming a 
non-profit, operating under the provisions of Self-Determination, P.L. 93-638, Title 1, or 
applying for Community Health Center funding. 

Minimizing the loss of Tribal identity was a core issue to the successful integration at 
these five study sites. Assurances and maintenance of cultural values were pivotal to 
their ability to establish an integrated health care system. Workforce issues were also 
addressed by many of the interviewees. Recruitment of needed personnel and gearing up 
to handle the increased volume of patients created through integration were identified as 
issues that needed to be addressed. None of these were identified as insurmountable 
barriers, but each site had to address them before, during, or shortly after integration. 

Based on the number of issues identified, the following are some initial recommendations 
for future policy development. 



52 



Develop a Technical Assistance Center for Tribes contemplating serving non-Natives. 
This center could provide support to Tribes in the areas of governance models, 
reimbursement issues, billing and collections, grant development, risk management, 
pharmacy formularies, and networking. 

Pilot the establishment of a separate joint funding announcement open to all tribes 
(638 or self-governance). HRSA/BPC in conjunction with IHS could pilot test 
integration activities that would consolidate reporting requirements, pharmacy 
regulations, liability issues, etc. 

Provide technical assistance workshops in each IHS region. The first day would 
increase awareness of options available to tribes interested in providing integrated 
services and highlight Tribal entities that have successfully integrated services. The 
second day could focus on specific issues related to obtaining Community Health 
Center funding, e.g. infrastructure needs, regulatory differences governing Tribal 
versus CHC entities, software incompatibilities between IHS and BPC, conflicting 
policies/procedures, and grant development support. 



53 



VII. APPENDICES 



APPENDIX 1 

ADMINISTRATION QUESTIONS 
EXAMINATION OF INTEGRATION OF NATIVE AND NON-NATIVE HEALTH 

CARE 



Description of the health care services provided at the site 

1 . What types of services are provided on-site to both populations? 

2. Are there any eligibility requirements for either population? 

3 . What are your hours/days of operation? 

4. How many staff do you have and what are their disciplines? 
Type of health care facility 

5. What is your governance/management structure? 

6. What is your mission and has it changed since integration? 

7. What policies exist regarding eligibility? 

8. What type of employment arrangements exist? Have these changed with the 
implementation of integration? 

History of health care facility and service integration 

9. Who initiated or lead the integration efforts? 

10. What were the reasons or motivation for integration? What was primary reasons? 

1 1 . How was the non-Tribal community involved in the integration efforts? 
(Communication avenues/past experience with collaboration on other projects) 

12. How is the non-Tribal community currently involved? What communication 
avenues are used currently? 

13. What was the length of time it took to achieve integration? 

14. How big a role do you think leadership play in integration efforts? 
Funding/financial issues 

15. What funding source was used to start providing integrated services? 

16. What are your sources of funding for both Native American and non-Native 
American patients? (payor categories) 

17. How do you handle uncompensated care? Do you have a sliding fee scale policy? 

18. What are the sources of your operational budget? Have these changed since 
integration? 

Facilitators that enable integration 

19. In what ways have the community, tribe, or local organizations supported the 
integration of services? Who were your sources of support (community/Tribal)? 
Was there an agency/organization or consultant that was instrumental in 
implementing this process? (Planning, facilitation, or provision of resources) 

20. Was there a crisis that necessitated a change in service delivery? If so, please 
describe. 

21. Were there specific resources that became available that prompted this effort? If 
yes, please describe. 

Barriers encountered to integrating health care 

22. What barriers did you encounter during the initial stages of integration? 
(Financial/political/regulatory/malpractice coverage/geographic/capacity of bill - 
federal/state/Tribal) 



23. How did you overcome these barriers? 

24. What barriers were not overcome and what limits did that place on service 
delivery? 

25. What concerns if any, arose within the Tribal community about providing services 
to non-Tribal community members? 

26. How did other providers in the area perceive your efforts of integration? 
Results of integration 

27. Describe the quality of care since integration? 

28. How has access to care changed? 

29. What is the level of community support since integration? 

30. How has your financial stability changed since integration? Has your capacity to 
bill other payors improved? 

3 1 . What recruitment issues have you faced prior to integration and after? 

32. What are the issues of integration today that are different than the initial stages? 

33. What are the advantages? What is the one greatest benefit that has resulted from 
integration efforts? 

34. What are the disadvantages? Are your resources stretched thin because of the 
integration? 

35. On a scale of 1 to 10(1 being low, 10 being high), how well do you feel your 
facility is meeting the health care needs of Native Americans? 

36. On a scale of 1 to 10(1 being low, 10 being high), how well do you feel your 
facility is meeting the health care needs of Non-Native Americans? 

37. If you had an opportunity to do this again, would you? Why or why not? 

38. What do you consider the key factors that other tribes should consider if they are 
contemplating integration? 

39. What is your present relationship with the Indian Health Service? 

40. What else do you think we ought to know about your experience with integration? 



56 



APPENDIX 2 

COMMUNITY QUESTIONS 

History of health care facility and service integration 

1 . Who initiated or lead the efforts to provide services to anyone? 

2. What were the reasons or motivation for integration? What was primary reasons? 

3. How was the non-Tribal community involved in the integration efforts? 
(Communication avenues/past experience with collaboration on other projects) 

4. How is the non-Tribal community currently involved? What communication 
avenues are used currently? 

5. What was the length of time it took to achieve integration? 

6. How big a role do you think leadership play in integration efforts? 
Facilitators that enable integration 

7. In what ways have the community, tribe, or local organizations supported the 
integration of services? Who were the sources of support (community /Tribal)? 
Was there an agency/organization or consultant that was instrumental in 
implementing this process? (Planning, facilitation, or provision of resources) 

8. Was there a crisis that necessitated a change in service delivery? If so, please 
describe. 

9. Were there specific resources that became available that prompted this effort? If 
yes, please describe? 

Barriers encountered to integrating health care 

10. What barriers were encountered during the initial stages of integration? 
(Financial/political/regulatory/malpractice coverage/geographic/capacity of bill - 
- federal/state/Tribal) 

1 1 . How were these barriers overcome? 

12. What barriers were not overcome and what limits did that place on service 
delivery? 

13. What concern, if any, arose within the Tribal community about providing services 
to non-Tribal community members? 

14. How did other providers in the area at the time of integration? Did they perceive 
these efforts of integration as a duplication of services or competition? 

Results of integration 

15. Describe the quality of care since integration? 

16. How has access to care changed? 

17. What is the level of community support since integration? 

18. What are the issues of integration today that are different than the initial stages? 

19. What are the advantages? What is the one greatest benefit that has resulted from 
integration efforts? 

20. What are the disadvantages? 

21. On a scale of 1 to 10(1 being low, 10 being high), how well do you feel your 
facility is meeting the health care needs of Native Americans? 

22. On a scale of 1 to 10(1 being low, 10 being high), how well do you feel your 
facility is meeting the health care needs of Non-Native Americans? 

23. If you had an opportunity to do this again, would you? Why or why not? 



57 



24. What do you consider the key factors that other tribes should consider if they are 
contemplating integration? 

25. What else do you think we ought to know about your experience with integration? 



58 



00 

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58 Villages with Health 
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Health, CD, Chiropractic 


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Corporation (Nome) 


Maniilaq Health 
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Health Corporation 
(Bethel) 


Benewah Medical 
Center 


Feather River Tribal 
Health 


Montezuma Creek 
Clinic 


Shoalwater Bay 
Clinic 


Confederated Tribes 
of Siletz Indians 


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Clinic 


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of Minneapolis 


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«n 



APPENDIX 4 

PARTICIPATION CONFIRMATION FORMS 



60 



Participation Confirmation 
Examination of Integration of Native and Non-Native Health Care 



We agree to participate with Mountain States Group, Inc. (MSG) through a contract with 
the Federal Office of Rural Health Policy in the study "Examination of Integration of 
Native and Non-Native Health Care" 

We will provide information and support to this study by identifying 10 or more 
individuals to serve as key informants and assisting project staff in contacting and 
scheduling interviews. These individuals will possess knowledge about our facility's 
integration efforts. 

Project staff will conduct these interviews in a sensitive and courteous manner and will 
respect any requests for anonymity or confidentiality. Once the information gathered 
from the interview process is written up, we will share it with the facility's contact person 
and will be responsive to any requests concerning the content prior to inclusion in the 
draft report. 

We recognize we will be one of the five sites selected nationally for this study and by 
signing this form agree to participate. 



Facility Contact: Jerry Waukau 

Name of Facility: Menominee Tribal Clinic 

Address: P.O. Box 970. Keshena. Wl 54135 

Telephone Number: (715)799-3361 

Signature of Facility Contact: fM^^- "^ v Wvjyi-g>-i\ 

Date: ^ //L/C*/ 



61 



Participation Confirmation 
Examination of Integration of Native and Non-Native Health Care 



We agree to participate with Mountain States Group, Inc. (MSG) through a contract with 
the Federal Office of Rural Health Policy in the study "Examination of Integration of 
Native and Non-Native Health Care". 

We will provide information and support to this study by identifying 10 or more 
individuals to serve as key informants and assisting project staff in contacting and 
scheduling interviews. These individuals will possess knowledge about our facility's 
integration efforts. 

Project staff will conduct these interviews in a sensitive and courteous manner and will 
respect any requests for anonymity or confidentiality. Once the information gathered 
from the interview process is written up, we will share it with the facility's contact person 
and will be responsive to any requests concerning the content prior to inclusion in the 
draft report. 

We recognize we will be one of the five sites selected nationally for this study and by 
signing this form agree to participate. 



Facility Contact: Maria Hunzeker 

Name of Facility: Feather River Tribal Health 

Address: 2145 5th Avenue. . Oroville. CA. 95965 

Telephone Number: 530-534-5394 

Signature of Facility Contact: 'ff)/i/!J/i T^lMdi^l 

I 



Date: V/7VA)^ 



62 



Participation Confirmation 
Examination of Integration of Native and Non-Native Health Care 



We agree to participate with Mountain States Group, Inc. (MSG) through a contract with 
the Federal Office of Rural Health Policy in the study "Examination of Integration of 
Native and Non-Native Health Care". 

We will provide information and support to this study by identifying 10 or more 
individuals to serve as key informants and assisting project staff in contacting and 
scheduling interviews. These individuals will possess knowledge about our facility's 
integration efforts. 

Project staff will conduct these interviews in a sensitive and courteous manner and will 
respect any requests for anonymity or confidentiality. Once the information gathered 
from the interview process is written up, we will share it with the facility's contact person 
and will be responsive to any requests concerning the content prior to inclusion in the 
draft report. 

We recognize we will be one of the five sites selected nationally for this study and by 
signing this form agree to participate. 



Facility Contact: Debra Hanks 

Name of Facility: Benewah Medical Center 

Address: 1 11 5 B Street. PO Box 388. Plummer. ID, 83851 

Telephone Number: 208-686-1 931 



Signature of Facility Contact: l^yfl 

Date: /)$ /.J//nQ 



63 



Participation Confirmation 
Examination of Integration of Native and Non-Native Health Care 



We agree to participate with Mountain States Group, Inc. (MSG) through a contract with 
the Federal Office of Rural Health Policy in the study "Examination of Integration of 
Native and Non-Native Health Care". 

We will provide information and support to this study by identifying 10 or more 
individuals to serve as key informants and assisting project staff in contacting and 
scheduling interviews. These individuals will possess knowledge about our facility's 
integration efforts. 

Project staff will conduct these interviews in a sensitive and courteous manner and will 
respect any requests for anonymity or confidentiality. Once the information gathered 
from the interview process is written up, we will share it with the facility's contact person 
and will be responsive to any requests concerning the content prior to inclusion in the 
draft report. 

We recognize we will be one of the five sites selected nationally for this study and by 
signing this form agree to participate. 



Facility Contact: Donna Singer 

Name of Facility: Montezuma Creek Clinic 

Address: PO Box 130. , Monte Zuma Creek, UT, 8451 1 

Telephone Number: 435-651 -3291 / 

Signature of Facility Contact: 

Date: / ■ ■'•/-■ i 



Liga NJ / 



64 



Participation Confirmation 
Examination of Integration of Native and Non-Native Health Care 



We agree to participate with Mountain States Group, Inc. (MSG) through a contract with 
the Federal Office of Rural Health Policy in the study "Examination of Integration of 
Native and Non-Native Health Care". 

We will provide information and support to this study by identifying 10 or more 
individuals to serve as key informants and assisting project staff in contacting and 
scheduling interviews. These individuals will possess knowledge about our facility's 
integration efforts. 

Project staff will conduct these interviews in a sensitive and courteous manner and will 
respect any requests for anonymity or confidentiality. Once the information gathered 
from the interview process is written up, we will share it with the facility's contact person 
and will be responsive to any requests concerning the content prior to inclusion in the 
draft report. 

We recognize we will be one of the five sites selected nationally for this study and by 
signing this form agree to participate. 



Facility Contact: Joe Cladouhos 
Name of Facility: Norton Sound Regional Corporation 
Address: PO Box 966. . Nome. AK. 99762 

Telephone Number: 907-443-3233 ^~. * 

Signature of Facility Contact:. ^^ &* CV^iX/ 



Date: 



j-t9~a* ; 



/ 




65